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01/11/2006 11:58 NEW !•Ir- T PETROLEUM -> 12094683433 NO.024 P003
<br /> PROQRAM CONSOUDA,TEA FO t I�� Q
<br /> TANKS I
<br /> UNDERGROUND STORAGE TANKS - FACILITY
<br /> (Ono page per site) 'Page,W„_of
<br /> 1 TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT S.CHANGE OF INFORMATION El 7,PERMANENTLY CLOSED SITE 400•
<br /> (Check one item oaly) ❑4.AMENDED PERMIT(Specify change) ❑8.TANK REMOVED
<br /> i ❑6.TMOORARY SIM CLOSURE
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<br /> BUSINESS NAME(Sam asrACILITYNAWo►DRA-NingeusiumsAa) )• I✓ACM"Y
<br /> ° Fla Ci Shell ID# F A 0 0 0 : 7' 1 4 0 t.
<br /> NEAREST CROSS STREET 401. EACH=OWNER TYPE Lj A.LOCAL AGENCY/DISTRICT* 40•
<br /> Hwy 12 ❑1.CORPORATION [15.COUNTY AGENCY*
<br /> BUSINESS 2g 1.GAS STATION [13.FARM Lj 5.COWaRCiAL 403' ®2,IWIDUAt [16.STATE AGENCY*
<br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR [:16.OTHER ❑3.PARTNERSHIP [17.FEDERAL AGENCY*
<br /> TOTAL NUMBER OF TANKS 404' is facility on Indian Reservation 405. *If o,7w of UST is a public agency,name of wpanlisor of division,section or 406-
<br /> REMAINING
<br /> 0.REMAINING AT SITE or oust lands? office which operates the UST. (This is the contact person for the tank records.)
<br /> 3 ❑Yes ®No
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<br /> PROPERTY OWNER NAME 407PHONE 408.
<br /> J.Gilbert Moore 916)443-0890
<br /> ? MAU ING OR STREET ADDRESS 409.
<br /> 18311 e Street
<br /> CITY 4i0• STATE 41t. .,ZIP CODE 412.
<br /> Sacramento CA 95814
<br /> PROPERTY OWNER TYPE Lj 1.CORPORATION 10 2.INDIVIDUAL LJ 4.LOCAL AGENCY!DISTRICT LJ 6.STATE AGENCY 413'
<br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY
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<br /> TANKOWNERNAME ata. PHONE. 415.
<br /> J.Gilbert Moore (916)443 os90
<br /> MAILING OR STREET ADDRESS alb.
<br /> 183116*Street
<br /> CITY 411. STATE 4ie. ZIP CODE 419.
<br /> Sacramento CA 95814
<br /> TANK OWNER TYPE ❑L CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420,
<br /> 03-PARTNERSHIP ❑5.COUNTY AGENCY ❑7,FEDERAL AGENCY
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<br /> INDICATE METHOD(s) O 1,sP Y INSUR1;i7 ❑d.SURETY BOND Q 7.STATE FUND [3 10.LOCAL GOVT ItffXiANM az2,
<br /> 02-
<br /> 2.GUARANTEE O 9,1 BTn R OF CREDrr N S.STATE FUND&CFO LET= ❑99.OTIER:
<br /> ❑3.INSURANCE O 6•EWRTION ❑9.STATE FUND dt CD
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<br /> Check me box to iodic0te which address shouldbe used for legal notifications and mailing.
<br /> Legal notifications and mailings will be sent to the tank owner unless box I of 2 is checked ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER 4z-
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<br /> Certification: I cart*t49 the information provided herein is true and accurate to the best of my knowledge.
<br /> SIGNATURE OF APPLICANT DATE424 PHONE 425.
<br /> (916)443-0890
<br /> NAW OF APPLICANT(punt) 426' TITLE OF APPLICANT 4a�.
<br /> J,Gilbert Moore Owner
<br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE.CERTIFICAM NUMBER(Agency aero only) a2g.
<br /> (See Data Element 1,above.
<br /> UPCF Hwfwre-a(1199)-I/2 bttp://www.unidors.org Rev.01"0
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